A guidebook for New Yorkers

with Medicaid

Now is the time to join ahealth plan

Getting Started

Choosing your health plan and doctor is important and it’s easy! Best of all, you will have a plan and a team of doctors to help you take good care of your health. Let’s get started by answering some questions you may have.

Does everyone join a health plan? Most people must join a plan. Some people have a special reason to keep regular Medicaid. Please see the section “Who Keeps Regular Medicaid.”

When should I join? It’s best to join right away! Please join no later than the day on your enrollment letter. Otherwise, New York State will choose a plan for you.

What if my county offers one health plan? You will be enrolled in that plan but it is just as important that you choose your doctor, so please contact us.

Need help? Not a problem. Your managed care worker at your local Social Services office or a Medicaid Choice counselor will be happy to assist you!

1

Table of Contents2 Joining a Health Plan

4 Health Plan Services

10 HIV Special Needs Plan

10 Health and Recovery Plans

11 Who Keeps Regular Medicaid

New York Medicaid ChoiceAsk. Choose. Enroll.

1-800-505-5678TTY: 1-888-329-1541

Monday through Friday, 8:30 am to 8:00 pm Saturday, 10:00 am to 6:00 pm

Visit us at nymedicaidchoice.com

New York State Medicaid managed care enrollment program.

2

A health plan will provide your care by working with a group (network) of doctors, clinics, hospitals and pharmacies.

You will choose one of the doctors from the health plan to be your Primary Care Provider (PCP). You will go to your PCP and the other doctors of the plan for most of your care.

Helpful tips when selecting a plan

1. Look over your list of health plans, and then call New York Medicaid Choice or your managed care worker at your local Social Services office.

2. Ask questions, like the ones on the next page. These will help you compare health plans and narrow down your choices.

Joining a Health Plan

“Which health plan...?“n works with the doctors I go to now?

n has doctors nearest to where I live or work?

n has doctors who speak my language?

n works with the clinic, hospital and pharmacy I want to use?

n offers services to help people with HIV? (See page 10)

n offers services to help people with mental health or substance use problems? (See page 10)

For answers to your questions, or to enroll, speak to a Medicaid Choice counselor or to your managed care worker at your local Social Services office.

How to enroll in a planThere are three easy ways to enroll (join a health plan)

• By Phone Call New York Medicaid Choice at 1-800-505-5678 (TTY: 1-888-329-1541).

• Online Go to nymedicaidchoice.com and click “Enroll”.

• By Mail Fill out and mail back the Health Plan Choice Form.

Before you select a new PCP, call the doctor’s office to find out if he or she is taking new patients.

3

Your First 90 DaysIf your county offers more than one health plan choice, you have up to 90 days, starting from your first day of enrollment, to decide if you will stay with your health plan or change plans. After this 90-day period, you must stay with the plan for the next nine months.

Note: Some individuals may be able to transfer to an HIV Special Needs Plan or Health and Recovery Plan. These individuals may transfer at any time. Contact New York Medicaid Choice at 1-800-505-5678 for more information (See page 10).

Health Plan Services

4

5

Health plans also provide:

n Mental health services

n Substance use services

n Family planning services You may go to your health plan or to a Medicaid provider for these services.

Pharmacy ServicesYou can go to any pharmacy that accepts your health plan card.

Your plan will inform you about its group of pharmacies and list of covered drugs (medicine).

Basic Services:n Doctor visits and hospital stays

n Regular check-ups and shots

n Emergency care

n Referrals to specialists when needed

n Prescribed medicine

n Health services at your home; such as home health aides and personal care

n Other services, such as eye care, dental care, medical equipment, hearing aids, HIV testing and counseling

6

Nursing Home ServicesHealth plans cover long-term stays for adults in a nursing home. Your plan will cover medical supervision, 24-hour nursing care, other services and support. Permanent stays at a nursing home must be approved by the Local Department of Social Services.

Note: Health and Recovery Plans do not cover long term stays in a nursing home.

Your Doctors Your PCP or health plan will be available to you at any time of the day or night. Your PCP will provide most of your care and will get to know your medical needs.

ReferralsYou will need a referral from your PCP to see a specialist and for other services. You may get a standing referral if you see the specialist often.

You will not need a referral from your PCP for the following services:

n Emergency care

n Family planning

n Vision services

n Mental health services

n Substance use treatment

Member Services DepartmentAll health plans have a Member Services Department to answer your questions and help resolve any problems with your doctor or health care. Member Services will help those health plan members needing special accommodations or extra support, such as:

n Help with their health care appointments and forms

n Medical offices that are wheelchair accessible or that offer other accommodations

n Booklets in large print or in audio format and TTY services for people who have trouble hearing or speaking

n Case management services

n Transitional care services (If your provider leaves the health plan or you change health plans, your health plan will work to make sure your ongoing care is not interrupted.)

7

8

You will receive a Member Handbook describing your plan’s services and a Provider Directory with the plan’s network of doctors, hospitals and pharmacies.

Health Plan Members have certain rights, such as:

n A choice of PCPs

n An appointment within 24 hours for urgent care and within 48 to 72 hours for routine care

n Receiving a second opinion about certain medical conditions from another provider in your plan

n Having all information about your health care kept confidential

n Asking for the clinical review criteria, (medical standards) the plan uses to make decisions about your care

n Complaining to the health plan, State Department of Health or New York Medicaid Choice

n Asking for a fair hearing if your plan has denied, stopped or reduced treatment or services you think you should get

Restricted ServicesMisusing your medicine or other plan services is not allowed and will limit your services to only certain providers and pharmacies.

Problem-solvingDon’t hesitate to call the plan’s Member Services representative for help with solving a problem with your doctor or services. You may also:

n Call New York Medicaid Choice at 1-800-505-5678 (TTY: 1-888-329-1541) or your managed care worker at your local Social Services office

n If you applied through the New York State of Health marketplace call 1-855-355-5777

n Call the State Department of Health Complaint Line at 1-800-206-8125 Monday through Friday, 8:30 am to 4:30 pm

n Ask for a fair hearing Ask for a fair hearing if you believe a decision about your Medicaid benefits or health plan enrollment is wrong or is taking too long. If your health plan denies, stops or reduces covered services you think you should have, your health plan’s member handbook explains how you can ask the plan to look at your case again and ask for a fair hearing.

9

10

HIV Special Needs PlanAn HIV Special Needs Plan (HIV SNP) is a Medicaid health plan that provides services to adults who are living with HIV or who are transgender or qualify as homeless. Your dependent children can also enroll in a HIV SNP with you. HIV SNPs cover all basic health care services and specialty services important to people who are living with or at risk of HIV/AIDS. The doctors, nurses and other providers who participate in an HIV SNP understand the special care needs facing people living with HIV/AIDS.

Health and Recovery PlansA Health and Recovery Plan (HARP) is a health plan option for adults who are receiving mental health and/or substance use services. HARPs offer the same set of benefits covered by other health plans. HARPs also cover extra support and services that can help you find a job, find housing or get other community services.

Speak to your mental health specialist or other care provider about joining a HARP. You may also call New York Medicaid Choice for more information.

Special Needs Health Plans

Some New Yorkers have a special situation that allows them to stay with regular Medicaid. They are either exempt or excluded from Medicaid managed care. If any of these situations apply to you, please speak to your managed care worker at your local Social Services office or to a Medicaid Choice counselor for more information.

Who Can Stay with Regular Medicaid

n People who live in facilities for the developmentally disabled

n Residents of an Article 819 long term alcohol or substance use facility

n People who are being treated for a chronic medical condition for 6 months or more by a fee-for-service Medicaid specialist who is not in a Medicaid health plan. (This exemption is limited to a 6 month period and for one time only)

n Adults in waiver programs: Nursing Home Transition and Diversion (NHTD), Office of People with Developmental Disabilities (OPWDD), Traumatic Brain Injury (TBI)

11

Who Keeps Regular Medicaid

New York Medicaid Choice is New York State’s Medicaid managed care enrollment program.

American Indian/ Alaskan NativeAmerican Indians/Alaskan Natives may join a health plan or keep using their Medicaid card for services. If you join a health plan, you may get services from your plan’s doctors or local tribal health center.

Who Must Stay with Regular Medicaidn People in hospice programs at the

time of enrollment

n Children or adults who live in state psychiatric or residential treatment facilities

n People who will get Medicaid only after they spend some of their own money for medical needs (spend-down cases)

n People with other full benefit health insurance

n Infants living with their mothers in jail or prison

n Children who are blind or disabled and living apart from their parents for 30 days or more

n People eligible for the Medicaid Cancer Treatment Program: Breast, Cervical, Colorectal and Prostate Cancer (MCTP)

12

New York Medicaid ChoiceAsk. Choose. Enroll.

1-800-505-5678TTY: 1-888-329-1541

Monday through Friday, 8:30 am to 8:00 pm Saturday, 10:00 am to 6:00 pm

Visit us at nymedicaidchoice.com

New York State of Health is New York’s health plan marketplace. People can go to the marketplace to get affordable health insurance or learn if they qualify for Medicaid or other health programs.

If you now get Medicaid, you do not need to do anything at this time but you should know about NY State of Health.

For more information, visit the website at www.nystateofhealth.ny.gov or call 1-855-355-5777.

New York State of Health The official health plan marketplace

UN-GUIDE-E-0719

Follow us on:

health.ny.gov facebook.com/NYSDOH

twitter.com/HealthNYGov youtube.com/NYSDOH

This booklet is available on CD and large print editions.

To get a copy, please call New York Medicaid Choice at

1-800-505-5678.

For people who use TTY: 1-888-329-1541.